Applying HFMEA to Prevent Chemotherapy Errors

  • Authors:
  • Chia-Hui Cheng;Chia-Jen Chou;Pa-Chun Wang;Hsi-Yen Lin;Chi-Lan Kao;Chao-Ton Su

  • Affiliations:
  • Quality Management Center, Cathay General Hospital, Taipei, Taiwan;Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan 300;Department of Otolaryngology, Cathay General Hospital, Taipei, Taiwan and School of Medicine, Fu Jen Catholic University, Taipei County, Taiwan and Department of Public Health, College of Public H ...;Department of Pharmacy, Cathay General Hospital, Taipei, Taiwan;Department of Pharmacy, Cathay General Hospital, Taipei, Taiwan;Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan 300

  • Venue:
  • Journal of Medical Systems
  • Year:
  • 2012

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Abstract

To evaluate risk and vulnerability in the chemotherapy process using a proactive risk analysis method. Healthcare failure mode and effect analysis (HFMEA) was adopted to identify potential chemotherapy process failures. A multidisciplinary team is formed to identify, evaluate, and prioritize potential failure modes based on a chemotherapy process flowchart. Subsequently, a decision tree is used to locate potential failure modes requiring urgent improvement. Finally, some recommended actions are generated and executed to eliminate possible risks. A total of 11 failure modes were identified with high hazard scores in both inpatient and outpatient processes. Computerized physician order entry was adopted to eliminate potential risks in chemotherapy processes. Chemotherapy prescription errors significantly decreased from 3.34% to 0.40%. Chemotherapy is regarded as a high-risk process. Multiple errors can occur during ordering, preparing, compounding, dispensing, and administering medications. Subsequently, these can lead to serious consequences. HFMEA is a useful tool to evaluate potential risk in healthcare processes.